Residency redesign helps patients and pleases doctors

Where: The 72-bed medicine ward of Boston's Faulkner Hospital, a community teaching hospital
affiliated with Brigham and Women's Hospital.

The issue: Increasing the educational value of residency for trainees while not compromising
patient care.

Background

The leaders of the Brigham and Women's residency program had a growing sense that
their trainees were getting a less-than-ideal educational experience, with much of
their time taken up by patient care to the detriment of learning.

“We felt like our trainees were being consumed by the rapid turnover of patients,
the high patient load, and the turnover of the residents with the duty-hour requirements,”
said Graham T. McMahon, MD, assistant professor of medicine at Harvard Medical School
and physician at Brigham and Women's. “We resolved to see if we could come
up with a different way of doing things that might optimize the educational experience
while at the same time studying whether it might actually make a difference for patients.”

How it works

The program leaders designed an experimental general medicine service, which they
called the Integrated Teaching Unit (ITU). Two teams were created, each with two attendings
(one hospitalist and the other an internist or specialist), two residents and three
interns. Each team conducted bedside rounds together every morning, and at least one
of the physicians conducted additional teaching and reviewed the trainees' progress
at the end of the day. The interns also had less frequent call than normal—they
were on all night every sixth night, instead of covering until 10 p.m. every fourth
night. The patient load for the team was capped at 15.

Results

After a year, the educators compared the new model with the usual system (one resident,
two interns, multiple attendings per team) in a study published in the April 8 New England Journal of Medicine. Trainees on the new teams were more satisfied, spent twice as much time in learning
activities and had significantly fewer patients at a time (average census of 3.5 patients
per intern vs. 6.6).

The satisfaction of both attendings and trainees with some of the changes was also
observed anecdotally. “The dual-attending model was very popular with everybody.
Going back to bedside team rounds, which has become a vanishing entity in U.S. medicine,
was also very popular,” said Dr. McMahon. There was support even for some of
the changes that the program designers had not expected trainees to like. “The
fact that they were on call through the night, when they were on call, was not as
unpopular as we thought at all. In fact, our interns appeared to appreciate that continuity,”
he said.

How patients benefit

The really unexpected results appeared when the researchers compared patient outcomes
between the two teams. On the ITU service, 26 patients (or 1.4%) died, compared to
48 (2.3%) of those treated normally. “We were personally very surprised that
there was such a difference in overall patient survival,” said Dr. McMahon.
“When we adjusted for everything from case mix to complexity of the patients
or their other factors, it still was highly significant.”

The gains in survival were also accomplished with no loss in efficiency. The differences
weren't significant, but length of stay and 30-day readmissions on the ITU service
were lower than both the regular service and national averages. “The general
concern before we ran the study was that if you cap teams at a census cap—in
this case 15—then the teams will have little incentive to discharge patients
efficiently,” said Dr. McMahon. “We found the opposite.”

The challenges

Although the project had many successes, not every aspect of the intervention worked
out, such as a plan to group patients being cared for by a team in one area. “We
worked hard to try to regionalize patient care into the team-based pods and we simply
couldn't make that work,” said Dr. McMahon. A planned post-discharge follow-up
clinic also didn't work out (see sidebar).

Lessons learned

The results of the experiment indicate that a new model of residency training is possible,
and given the patient mortality statistics, maybe necessary. “One of the implications
of those two numbers [26 vs. 48 deaths] is that the current standard of inpatient
residency care could be improved,” Dr. McMahon said.

The researchers also calculated the costs of the program, and concluded that the extra
spending, on attendings' salaries and providers (such as physician assistants) to
care for patients who would otherwise be treated by residents, could be mostly offset
by cost savings from shorter lengths of stay on the ITU since the hospital was readily
able to fill empty beds. “Ultimately, the program was going to cost us, after
all the deductions, less than approximately $100,000 per year,” said Dr. McMahon.

“We went out and showed that not only can you do this, but that thoughtful
investment in resident education can result in improved patient care, improved resident
satisfaction and improved efficiency, all at the same time,” Dr. McMahon said.

Next steps

The program has been expanded from Faulkner Hospital to the main Brigham and Women's
hospital, and program leaders continue to track the results. “The data appears
to be holding. Even when we took it out of a community hospital and put it in a major
academic center, we're starting to see very similar improvements in length of stay
and efficiencies,” said Dr. McMahon.

Words of wisdom

“Remember that trainees are there to learn and to work to learn,” Dr.
McMahon said.

Failure within a success

When educators at Brigham and Women's Hospital were developing their experimental
model of residency, they decided to include a post-discharge clinic, where patients
who had been treated and released by the medicine service could receive follow-up
care from the residents.

“The idea was that some of our patients have no primary care physician, and
some of our patients have great difficulty getting back in to see their primary care
physician and were being left in a limbo between discharge and their next doctor's
office visit,” said Graham T. McMahon, MD, assistant professor of medicine
at Harvard Medical School.

The project leaders also thought the experience would be good for the residents. “Because
patient hospitalizations are so short, residents don't really get to see the spectrum
of the disease that they're caring for. They don't get to see their patients really
substantially improve as a result of the decisions that they make and don't get to
see the impacts of the discharge plan that they come up with,” Dr. McMahon
said.

But the reality turned out much different from their expectations. “It didn't
work very well at all. In fact, it was probably the most unpopular thing that we did,”
said Dr. McMahon.

One problem was that the outpatient visits were difficult to fit into the schedule
of inpatient medicine. “The team might be seeing a patient in the emergency
room or on rounds in the morning, or going to an educational conference and they'd
get a call saying, ‘Mrs. Smith is here for her post-discharge clinic. Will
somebody come and see her?’”

Even when the follow-up visits were scheduled in advance for times that should have
been convenient, the residents found the transition from one practice environment
to the other time-consuming and dissonant, Dr. McMahon said.

The clinic also failed to provide the sense of fulfillment for residents that the
educators had expected. “Residents want to be done with a patient when they
discharge,” said Dr. McMahon. “Adding that additional expectation that
you think about and care about patients after you discharge them was a mind shift
that our residents found very difficult to accept and, in fact, resented and pushed
back against quite strongly.”

To top it off, even the patients didn't like the clinic, Dr. McMahon said. “It
seemed disruptive to the patient. They didn't know who their doctor was: Should they
be going to a primary care doctor now? Should they come back to this clinic? Who should
they be trying to get in to see when they have a problem?”

“In general the program had more challenges than successes,” said Dr.
McMahon. Consequently, the researchers discontinued the follow-up clinic experiment.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.